FUNDAMENTALS OF NURSING

Module 3: Diagnosing

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

Objectives
1. Differentiate nursing diagnoses according to status.
2. Identify the components of a nursing diagnosis.
3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.
4. Identify the basic steps in the diagnostic process.
5. Describe various formats for writing nursing diagnoses.
6. List guidelines for writing a nursing diagnosis statement.
7. Describe the evolution of the nursing diagnosis movement, including work currently in
progress.

Key Concepts
1. There are four types of nursing diagnoses:
• Actual - an actual diagnosis is a client problem that is present at the time of
the nursing assessment. An actual nursing diagnosis is based on the presence
of associated signs and symptoms
• Health promotion - a health promotion diagnosis relates to clients’
preparedness to implement behaviors to improve their health condition.
• Risk - a risk diagnosis is a clinical judgment that a problem does not exist;
however, the presence of risk factors indicates that a problem is likely to
develop unless the nurse intervenes. There are no current signs or symptoms
at present.
• Syndrome - a syndrome diagnosis is associated with a cluster of other
diagnoses.
• Possible - statements describing a suspected problem for which additional data
are needed to confirm or rule out the suspected problem

2. A nursing diagnosis has three components:

• problem and its definition
- describes the client’s health problem or response for which nursing therapy
is given
- describes the health status clearly and concisely in a few words
- the purpose of the diagnostic label is to direct the formation of client goals
and desired outcomes
- may also suggest some nursing interventions

• etiology (related factors and risk factors)

- identifies one or more probable causes of the health problem, gives
direction to the required nursing therapy, and enables the nurse to
individualize the client’s care
- differentiating possible causes is essential because each may require
different nursing interventions.

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

• defining characteristics
- the cluster of signs and symptoms that indicate the presence of a
particular diagnostic label
- for actual nursing diagnoses, the defining characteristics are the client’s
subjective and objective signs.
- for risk diagnoses, no signs and symptoms exist; thus, the factors that
cause the client to be more vulnerable to the problem form the etiology

3. Differences among nursing diagnoses, medical diagnoses, and collaborative

problems are based on description, orientation, responsibility for diagnosing,
treatment orders, nursing focus, nursing actions, duration, and classification system.

Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

4. Nursing diagnoses describe human responses to disease processes or health

problems.

They consist of one-, two-, or three-part statements including problem and etiology.
Nursing diagnoses are oriented to the client. The nurse is responsible for diagnosing
and ordering most interventions to prevent and treat the health problem.

Most interventions are independent nursing actions, and the nursing diagnosis may
change frequently. There is a classification system in development and being used
but it is not universally accepted.

The basic two-part statement includes the following:

• Problem (P): statement of the client’s response (NANDA label)
• Etiology (E): factors contributing to or probable causes of the responses.

The two parts are joined by the words related to rather than due to. The phrase due to
implies that one part causes or is responsible for the other part. By contrast, the phrase
related to merely implies a relationship.

The basic three-part nursing diagnosis statement is called the PES format and includes
the following:
1. Problem (P): statement of the client’s response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the response
3. Signs and symptoms (S): defining characteristics manifested by the client.
Actual nursing diagnoses can be documented by using the three-part statement because
the signs and symptoms have been identified. This format cannot be used for risk
diagnoses because the client does not have signs and symptoms of the diagnosis.

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

One-part statements, such as health promotion diagnoses and syndrome nursing

diagnoses, consist of a NANDA label only. NANDA has specified that any new wellness
diagnoses will be developed as a one-part statement beginning with the word willingness.

5. Medical diagnoses describe disease and pathology, do not consider human

responses, usually consist of a few words, and are oriented to pathology. The primary
care provider is responsible for diagnosing and ordering primary interventions. Nurses
implement medical orders for treatment and monitor the status of the client’s condition.
Diagnosis remains the same while disease is present, and there is a well-developed
classification system accepted by the medical profession.

Medical Diagnosis vs Nursing Diagnosis

Medical Diagnosis Nursing Diagnosis

Focuses on illness, injury or disease process Focuses on RESPONSES to
ACTUAL or potential health problems or life
processes
Remains constant until a cure is effected Changes as the client’s
response and/or the health problem changes
Identifies conditions the health care Identifies situations in which the nurse is
practitioner is licensed and qualified to treat licensed and qualified to intervene

Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

6. Collaborative problems involve human responses, mainly physiological complications

of disease, tests, or treatments. They consist of two-part statements of
situation/pathophysiology and the potential complication. Collaborative problems are
oriented to pathophysiology, and nurses are responsible for diagnosing.

Nurses collaborate with physicians and other healthcare professionals to prevent and
treat. Medical orders are required for definitive treatment. The nursing focus is to
prevent and monitor for onset and status of condition. The duration of the problem is
present when the disease or situation is present, and there is no universally accepted
classification system.

7. The diagnostic process includes analyzing data; identifying health problems, risks,
and strengths; and formulating diagnostic statements. To analyze data, the nurse
must compare data against standards (identify significant cues), cluster the cues
(generate tentative hypotheses), and identify gaps and inconsistencies.

To analyze data, the nurse compares data with standards or norms, generally
accepted measures, rules, models, or patterns, looking for negative or positive
changes in the client’s health status or pattern, variation from norms of the population,
or a developmental delay.

Another step in analyzing is to cluster cues to determine the relationship of facts,

determining whether patterns are present or represent isolated incidents, and whether
the data are significant.

• Data clustering involves making inferences about the data, interpreting

possible meaning of the cues, and labeling the cues with tentative diagnostic
hypotheses. Inconsistencies are conflicting data.
• Possible sources of conflicting data are measurement errors, expectations, and
inconsistent or unreliable reports.
• All inconsistencies must be clarified before valid patterns can be established.
• The nurse and the client then identify problems that support tentative actual,
risk, and possible diagnoses, and the nurse must determine whether the client’s
problem is a nursing diagnosis, a medical diagnosis, or a collaborative problem.
The nurse and client must establish the client’s strengths, resources, and
abilities to cope. The last step in the diagnostic process is formulating
diagnostic statements.

Ins�tute of Health and Sciences and Nursing

 Module 3: Diagnosing

8. There are five variations of the basic formats:

• Writing unknown etiology when the defining characteristics are present but the
nurse does not know the cause or contributing factors
• Using the phrase complex factors when there are too many etiologic factors or
when they are too complex to state in a brief phrase
• Using the word possible to describe either the problem or the etiology when the
nurse believes more data are needed about the client’s problem or the etiology
• Using secondary to divide the etiology into two parts, thereby making the statement
more descriptive and useful (the part following secondary to is often a
pathophysiological or disease process or a medical diagnosis)
• Adding a second part to the general response or NAND A label to make it more
precise

9. Guidelines for writing nursing diagnosis statements include:

• Write the statement in terms of a problem instead of a need
• Word the statement so that it is legally advisable
• Use a nonjudgmental statement
• Ensure both elements of the statement do not say the same thing
• Ensure cause and effect are stated correctly
• State the diagnosis specifically and precisely
• Use nursing terminology rather than medical terminology to describe the client’s
response

10. To improve diagnostic reasoning and avoid diagnostic reasoning errors, the nurse
should verify diagnoses by talking with the client and family, build a good knowledge
base and acquire clinical experience, have a working knowledge of what is normal,
consult resources, base diagnoses on patterns (i.e., behavior over time) rather than
an isolated incident, and improve critical thinking skills.

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 Module 3: Diagnosing

11. The first taxonomy—a classification system or set of categories arranged based on a
single principle or set of principles—was alphabetical. In 1982, NANDA accepted the
“nine patterns of unitary man” as an organizing principle. In 1984, NAND A renamed
the “patterns of unitary man” as “human response patterns.”

12. The human response patterns include:

• Exchanging: mutual giving and receiving
• Communicating: sending messages
• Relating: establishing bonds
• Valuing: assigning relative worth
• Choosing: selection of alternatives
• Moving: activity
• Perceiving: reception of information
• Knowing: meaning associated with information
• Feeling: subjective awareness of information

13. Diagnoses on the NAND A list are not finished products but are approved for clinical
use and further study. This system includes classification of nursing interventions (NI
C) and nursing outcomes (NOC), which are being developed by other research groups
and are linked to NANDA diagnostic labels.

Nursing Diagnosis
• A clinical judgment about individual family or community responses to health
problem processes
• A complex decision-making process that requires cognitive and intuitive skills,
experience and scientific knowledge base
• Nurses are responsible for diagnosing HUMAN RESPONSES to health related
issues and determine its effects on their daily living

Why Nursing Diagnoses?

1. Contribute to the identity of nursing as a profession

2. Provide mechanism for professional accountability

3. Facilitate nurses’ autonomy in judgments about client care

4. Contribute to the knowledge base of nursing as a science

5. Can be used as “key conceptual criteria around which standards are developed”
6. Used for communication of professional judgment

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 Module 3: Diagnosing

7. Contribute to continuity of care

8. Demonstrate effectiveness of quality care

9. Promote collaboration among members of the health care team

10. Provide mechanism for costing out nursing services

11. Provide basis for generating computerized NCP

12. Provide basis for intershift reporting

13. Use as basis for quality assurance programs

Includes 2 phases:

1. Analysis is the categorization of the data gathered and identification of gaps

2. Synthesis is determination of patterns, norms, theories, models, health concerns and
delineation of relationships unique to the patient

STUDY QUESTIONS
1. What are the five types of nursing diagnoses?

2. A nursing diagnosis has three components. List the three components and give an
example of each.

3. List two examples each of a one-part, two-part, and three-part diagnostic statement.
Refer to the PES diagnosis in the module.

Reference: Berman, A. T. (2022). KOZIER & ERB’S FUNDAMENTALS OF NURSING :

concepts, process and practice. (11th ed.). Prentice Hall.

Ins�tute of Health and Sciences and Nursing